UB-04 Billing Guide for PROMISe Outpatient Hospitals

Transcription

1 Purpose of the Document Document at Font Sizes Signature pproval The purpose of this document is to provide a block-by-block reference guide to assist the following provider types in successfully completing the UB-04 claim form: Outpatient Hospital Clinic & Emergency Room Hospital Short Procedure Unit (SPU) Outpatient Rehabilitation Hospital The document contains a table with five columns and each column provides a specific piece of information as explained below: Provides the field number as it appears on the claim form. Provides the field name as it appears on the claim form. Lists one of four codes that denote how the should be treated. They are: Indicates that the must be completed. Indicates that the must be completed, if applicable. O Indicates that the is optional. Indicates that the should be left blank. Provides important information specific to completing the field. In some instances, the section will indicate provider specific completion instructions. Because of limited field size, either of the following type faces and sizes are recommended for form completion: Times New Roman, 10 point rial, 10 Point Other fonts may be used, but ensure that all data will fit into the fields, or the claim may not process correctly. Each batch of claims submitted UST be accompanied by 1 (one) properly completed Signature Transmittal ( 307). batch can consist of a single claim or as many as 100 claims. Go to the DHS Website to download a copy of the form with completion instructions.

2 EPSDT cute Care Hospitals and Hospital Based edical Clinic providers who wish to bill for an individual EPSDT office visit for an incomplete EPSDT screen should bill their service as an outpatient clinic visit with procedure code T1015 and their applicable pricing modifier (U4 or U5) and informational modifier EP. This service must be billed on the UB-04/837I. Providers should also use condition code 1 for EPSDT services. Incomplete EPSDT screens are office visits where the provider did not complete all of the required components listed on the periodicity schedule for the child s age group. Outpatient Hospital clinics / Independent edical Surgical Clinics who are billing EPSDT complete screens will bill on the CS-1500/837P. These providers should refer to the Program Fee Schedule and the CS-1500 Billing Guide for Early, and Periodic, Screening, Diagnosis, and Treatment (EPSDT) Services, for details on billing EPSDT complete screens. LRC Effective with dates of service on and after December 1, 2016, the DHS will pay inpatient hospitals (Provider Type 01 and Specialty 010) for LRC (Long cting Reversible Contraception); intrauterine devices and contraceptive implants in addition to maternity PR DRG. Hospitals must submit their claims for the LRC device on an 837I for Outpatient, Internet Outpatient Claim, or paper UB04 using the applicable LRC procedure code-modifier combinations identified in the attachment to Bulletin et al; titled Program Fee Schedule Updates for Certain Family Planning Services effective December 1, Ordering and Prescribing The Patient Protection and ffordable Care ct (C) added requirements for provider screening and enrollment, including a requirement that states require physicians and other practitioners who order or refer items or services for beneficiaries to enroll as providers. The Department of Health and Human Services regulation implementing this requirement can be found at 42 CFR Providers should check form locator 76 for further direction. 2

3 P PROISe 837 Institutional/UB-04 Claim 1 Provider, ddress, and Telephone 2 Unlabeled (Pay-To, ddress, and Pay-to Provider ID) Enter the information in 1 on the appropriate line: Line 1 Provider Line 2 Complete street address Line 3 City, state, and zip code Line 4 rea code and telephone number Enter the information in 2 on the appropriate line: Line 1 Pay-to Provider Line 2 Pay-to Street ddress Line 3 Pay-to City, State, and ZIP Line 4 Pay-to Provider ID (9-digit provider number and 4-digit service location) 3a Patient Control Enter the patient s unique alpha, numeric, or alphanumeric number assigned by the provider. You may enter up to 24 characters. DHS will capture and return 24 characters. Your patient s account number will appear on the R Statement when this is completed, which will make identifying claims easier when the beneficiary number is not recognized by DHS. 3b edical Record O Enter the designated medical/health record number that you have assigned to the beneficiary. This will hold up to 24 alphanumeric characters. The medical record number will not be displayed on the R Statement. 4 Type of Bill The UB-04 claim form may be used to bill for outpatient hospital care or to replace a claim for outpatient hospital care that was paid by. Enter the appropriate three-digit code to identify 3

4 P PROISe 837 Institutional/UB-04 Claim the type of bill being submitted. The format of the three-digit code is indicated below: 1. First digit: Type of facility always enter 1 to indicate hospital. 2. Second digit: Bill classification enter 3 to indicate outpatient or 4 for Hospital Special Treatment Room. 3. Third digit: Frequency enter 0, 1, 7, or 8. 0 Non Payment/Zero Claim This code is used when a bill is submitted to a payer and the provider does not anticipate a payment as a result of submitting the bill, but needs to inform the payer of the nonreimbursable care (that is, where patient pay is equal to or exceeds the amount billed). 1 dmit Through Discharge Claim This code is used for a bill that is expected to be the only bill received for a course of treatment. This includes bills representing a total course of treatment, and bills which represent an entire period of the primary third party payer. 7 Replacement of a Prior Claim This code is used when a specific bill has been issued for a specific Provider, Patient, Payer, Insured, and Statement Covers Period, and the bill needs to be restated in its entirety except for the same identity information. When using this code, the payer is to operate on the principle that the original bill is null and void, and the information present on this bill represents a complete replacement of the previously issued bill. This code replaces a prior claim. It does not simply adjust a prior claim. (Frequency 4

5 P PROISe 837 Institutional/UB-04 Claim 7 cannot be used to correct beneficiary or provider number errors. For those errors, submit bill with Frequency 8.) See 80 for a complete listing of Reason for djustment s. 8 Void/Cancel of Prior Claim This code is used to reflect the elimination of a previously submitted bill in its entirety for a specific Provider, Patient, Payer, Insured, and Statement Covers Period. When using Frequency 8 to return all monies paid, you are not required to backout each revenue code claim line submitted on the approved claim. 5 Federal Tax 6 Statement Covers Period (From/Through) Do not complete this. Enter the dates the beneficiary was treated in the facility. Use both the From and Through dates. Enter the dates in a 6-digit format (DDYY). Do not use spaces, slashes, dashes, or hyphens (for example, ). Paper UB04 Claims Only: For Observation Services, the Statement Covers Period must represent the timeframe the recipient was in observation status (i.e., admission date and discharge date from observation). Please do not apply the billing instructions to Internet or electronic claims. 7 Unlabeled Do not complete this. 8 (a, b) Patient a) Patient ID Do not complete this portion of the. 5

6 P PROISe 837 Institutional/UB-04 Claim b) Patient Enter last name, first name, and middle initial of the patient in 8b. Note: If submitting a claim for a newborn under the mother s beneficiary number, complete this with the name of the baby. If the baby s name is not available, you may enter Baby Boy or Baby Girl. 9 (a e) 10 Birthdate Patient ddress O Enter the address of the patient. a) Street b) City c) State d) ZIP e) Country Enter the birth date of the beneficiary in an 8- digit format (DDYYYY). Do not use spaces, slashes, dashes, or hyphens (for example, ). 11 Sex O O Newborn - If submitting a claim for a newborn under the mother s beneficiary number, you must complete this with the newborn s date of birth ll others, other than newborns. Enter for ale or F for Female. Newborn: If submitting a claim for a newborn under the mother s beneficiary number, you must complete this with the gender of the newborn. ll others, other than newborns. 12 dmission Date Do not complete this. 13 dmission Hour Do not complete this. 14 dmission Type Enter 1 for an emergency treatment the condition requires immediate medical attention 6

7 P PROISe 837 Institutional/UB-04 Claim and any time delay would be harmful to the patient. Enter 2 for an urgent treatment a condition such that medical attention, while not immediately essential, should be provided very early to prevent possible loss or impairment of life, limb, or body function. Enter 3 for an elective treatment. Enter 4 for a newborn treatment. Enter 5 for a trauma treatment. 15 Source of dmission If the beneficiary resides in a long term care facility, enter 5. This indicates that the beneficiary is exempt from copayment. 16 Discharge Hour Do not complete this form locator. 17 Patient Discharge Status Do not complete this form locator Condition s Enter the appropriate condition codes in s 18 through 28. For a complete listing and description of Condition s, please refer to the UB-04 Desk Reference, located in ppendix of the handbook. 29 ccident State Do not complete this. 30 (1, 2) Unlabeled Line 1 Do not complete Line 1 of this. Line 2 Do not complete Line 2 of this (a, b) Occurrence /Date Enter the appropriate Occurrence and date. Enter the dates in a 6-digit format (DDYY). Do not use spaces, slashes, dashes, or hyphens (for example, ). Complete s 31a through 34a before 7

8 P PROISe 837 Institutional/UB-04 Claim completing 31b through 34b. Occurrence codes should be entered in numerical sequence. For a complete listing and description of Occurrence s, please refer to the UB-04 Desk Reference, located in ppendix of the handbook. 35, 36 Occurrence Span and Dates Do not complete these s. 37 Unlabeled Do not complete this. 38 Unlabeled Do not place anything in this area of the claim form (a d) Value s and mount Enter the appropriate value codes and amounts. Value codes should be entered in numerical sequence. s 39a through 41a must be completed before s 39b through 41b. Value code 66 is used for Patient Pay only. Value 73 is used for Sequestration adjustment amount. Note: s of 1/1/2012, report edicare Co-Pay with a value code of 7. Note: When submitting a paper crossover claim on a UB04 claim form, use Value 73 (Sequestration adjustment amount). For a complete listing and description of Value s, please refer to the UB-04 Desk Reference, located in ppendix of the handbook. 42 Revenue s Enter the appropriate four-digit revenue codes to 8

9 P PROISe 837 Institutional/UB-04 Claim (1 22) (23) Unlabeled identify the delivered services. Paper UB04 Claims, Internet Claims, and Electronic Claims: Observation Procedure s G0378 and G0379; hospitals must use either Revenue 0760 or When billing for services involving a third-party payment, only one claim line may be billed on an invoice. For a complete listing and description of Revenue s, please refer to the Desk Reference for Outpatient Revenue s, located in ppendix of the handbook. Do not complete this row. 43 (1 22) Revenue Description Enter the appropriate narrative description to correspond to the related revenue codes found in 42. (23) Page of Do not complete this row. The back side of claim form must be left blank. DHS is not currently accepting double-sided, datapopulated claim forms. 44 (1 22) HCPCS / Rate / HIPPS / Enter the appropriate HCPCS s and modifiers. When billing for services involving a third-party payment, only one claim line may be billed on an invoice. When billing a Primary code with additional related (add-on) codes, the Primary code and the additional add-on code(s) must appear on the same claim. The Primary code UST appear on the claim first preceding the add-on codes, regardless of where the primary code appears on the claim. Note: Failure to follow this Billing procedure will result in the denial of your claim on edit 5529 Related Procedures ust be Billed Together, 5535 Primary ust be 9

10 P PROISe 837 Institutional/UB-04 Claim Billed Before dd-on, or 5536 Primary ust be Billed Before dd-on (Different). For a complete listing and description of odifier s, please refer to the odifier s. (23) Unlabeled Do not complete this row. 45 (1 22) Service Date Enter the applicable date(s) of service. Enter the dates in a 6-digit format (DDYY). Do not use spaces, slashes, dashes, or hyphens (for example, ). The Service Dates must fall between the From and Through dates entered in #6. Paper UB04 Claims Only: For Observation Procedure s G0378 and G0379, enter the observation admission date due to the field only facilitating a single date of service. Please do not apply the billing instructions to Internet or electronic claims. (23) Creation Date Creation Date and Total Charges Fields Enter the Claim Creation Date on line 23 of this. See the sample exhibit below: 46 Units of Service Enter the number of units, services, or items 10

11 P PROISe 837 Institutional/UB-04 Claim (1 22) provided. Paper UB04 Claims, Internet Claims, and Electronic Claims: For Observation Procedure s G0378, one unit is equal to one hour of observation. Please enter the number of hours via units that the patient was in observation status. Observation Procedure G0379 may only be billed with a single unit. Please refer to Bulletins and for additional information. 47 (1 22) (23) Total Charges Unlabeled (Total Charges) Enter total amount for each HCPCS code on the appropriate corresponding lines for the current billing period. Hospitals must show the usual and customary charge to the general public for covered services during the treatment. Claim and claim adjustment submissions must include only positive dollar amounts. Do not complete this. 48 (1 23) Non-Covered Charges Do not complete this. 49 (1 23) Unlabeled Do not complete this. Note #1: s 50 through 65, lines, B, and C, are designed to accommodate payer information. Line denotes the primary payer, Line B denotes the secondary payer, and Line C denotes the tertiary payer. s: edicare B = 2 Other Insurance = 1 and name of plan. 11

12 P PROISe 837 Institutional/UB-04 Claim edical ssistance = P Possible Payer Combinations: edical ssistance is the only payer (the beneficiary does not have any other resources): Complete 50() with the word P. edicare B is primary and edical ssistance is secondary: If edicare B is primary, complete 50() with the number 2. Complete 50(B) with P. Other insurance is primary and edical ssistance is secondary: If other insurance is primary, complete 50() with the number 1 and the name of the primary insurance plan (for example, 1 etna). Complete 50(B) with P. The patient has two other insurance plans, and edical ssistance: If edicare B is the primary insurance plan, complete 50() with the number 2. If another insurance plan is primary, complete 50() with the number 1 and the name of the primary insurance plan (for example, 1 etna) Complete 50(B) with the number 1 and name of the secondary insurance plan (for example, 1 Blue Cross) Complete 50(C) with P. When completing s 51 through 65, place the information applicable to the primary payer on line, the secondary payer on line B, and the tertiary payer on line C. 50 (, B, C) Payer Primary Payer edicare Part B Enter 2 to indicate edicare, if applicable. Commercial Insurance Enter the number 1 and the name of the insurance carrier to indicate commercial insurance, if applicable. P Enter P to indicate Pennsylvania edical ssistance. 51 (, B, C) Health Plan ID Do not complete this. 12

13 P PROISe 837 Institutional/UB-04 Claim 52 (, B, C) Release of Information Do not complete this. 53 (, B, C) ssignment of Benefits Do not complete this. 54 (, B, C) Prior Payments Primary Payer Due from Primary Payer Enter the amount of liability toward this hospitalization by any other insurance resource (other than edicare). edicare To ensure the proper use of the patient s edicare resources, bill edicare first for services provided to beneficiaries who may be eligible for edicare. i. Deductible Only If edicare applied the entire payment to the edicare Part B beneficiary s calendar year deductible, report the edicare pproved mount here. ii. Deductible and Coinsurance OR Deductible and Copayment OR Coinsurance OR Copayment Only If edicare applied part of the payment toward the edicare Part B beneficiary s calendar year deductible and assessed coinsurance or copayment toward the same service or edicare assessed coinsurance or copayment only, report the edicare Paid mount here. 13

14 P PROISe 837 Institutional/UB-04 Claim P Leave Blank there is no information to place in this. See 50, Note # 1, for the, B, C format rules. Only positive dollar amounts are to be entered for any payer and patient when billing. 55 (, B, C) Estimated mount Due Do not complete this. 56 NPI (National Provider Identifier) Enter the 10-digit National Provider Identifier number. 57 (, B, C) Other Provider ID Primary Payer O edicare Enter the edicare provider number. (Optional) O Commercial Insurance Enter the provider number. (Optional) P Enter the 9-digit provider number and 4-digit service location For example, ). (ust) Do not use slashes, hyphens, or spaces. See 50, Note # 1, for the, B, C format rules. 58 (, B, C) Insured s Primary Payer Because is the payer of last resort, complete the appropriate edicare or other private insurance information by entering the name of the person who owns the other insurance coverage. 14

15 P PROISe 837 Institutional/UB-04 Claim P Do not complete this portion of the. See 50, Note # 1, for the, B, C format rules. 59 (, B, C) Patient s Relationship to Insured Primary Payer Other Insurance If pplicable Complete the appropriate edicare or other private insurance information by entering the appropriate Patient s Relationship to Insured code. P Do not complete this portion of the. See 50, Note # 1, for the, B, C format rules. For a complete listing and description of Patient s Relationship to Insured, please refer to the UB-04 Desk Reference, located in ppendix of the handbook. Please note that the Patient s Relationship to Insured s are the same codes used electronically in the 837I. 60 (, B, C) Insured s Unique ID Primary Payer edicare Enter the patient s edicare HIC number as shown on the Health Insurance Card, Certificate of ward, Utilization Notice, Temporary Eligibility Notice, Hospital Transfer, or as reported by the Social Security office. Commercial Insurance Enter the policy number for the insurance company. P Enter the 10-digit beneficiary number as shown on the CCESS Card. 15

16 P PROISe 837 Institutional/UB-04 Claim See 50, Note # 1, for the, B, C format rules. 61 (, B, C) Insurance Group Primary Payer edicare Leave Blank. Commercial Insurance Enter the name of the group or plan through which insurance has been obtained. P Leave Blank. See 50, Note # 1, for the, B, C format rules. 62 (, B, C) Insurance Group Primary Payer edicare Leave Blank. Commercial Insurance Enter the insurance group number which identifies the group listed in 61. P Leave Blank. See 50, Note # 1, for the, B, C format rules. 63 (, B, C) Treatment uthorization s Primary Payer edicare Leave Blank. Commercial Insurance Leave Blank. P Enter the 10-digit prior authorization number. For additional information regarding authorization and your specific provider type, refer to the P PROISe Provider Handbook for 837 Institutional/UB-04 Claim, Section 7, or to the PSR, DRG, or CHR anuals. Do not enter a treatment authorization number for 16

17 P PROISe 837 Institutional/UB-04 Claim the following types of treatment: 1. edicare deductible or coinsurance for treatment with edicare Part. 2. Non-Pennsylvania facilities. See 50, Note # 1, for the, B, C format rules. Note: When completing this ), use the edical ssistance authorization number only, when applicable. Do not use a edicare or other insurance s prior authorization number. 64 (, B, C) Document Control Primary Payer edicare Leave Blank. Commercial Insurance Leave Blank. P When resubmitting denied claims, enter the original denied ICN number on the P line. For claim adjustments or voids, enter the ICN number of the last paid claim. See 50, Note # 1, for the, B, C format rules. 65 (, B, C) Employer Primary Payer edicare Leave Blank. Commercial Insurance Enter the name of the employer of the insured or possibly insured patient, spouse, parent, or guardian identified in 58. P Leave Blank. See 50, Note # 1, for the, B, C format rules. 66 DX Version Do not complete this. 17

18 P PROISe 837 Institutional/UB-04 Claim Qualifier 67 Principal Diagnosis For dates of discharge prior to October 1, 2015, enter up to five digits of the ICD-9-C code for the principal diagnosis; OR for dates of discharge on or after October 1, 2015, enter up to seven digits of the ICD-10-C code for the principal diagnosis. Do not include decimals. 67 ( H) Other Diagnosis For dates of discharge prior to October 1, 2015, enter up to five digits of the ICD-9-C code; OR for dates of discharge on or after October 1, 2015, enter up to seven digits of the ICD-10-C code for diagnoses, other than the principal diagnosis, in fields -H. 67 (I Q) Do not include decimals. Do not complete fields 67 I Q. 68 Unlabeled Do not complete this. 69 dmitting Diagnosis Do not complete this. 70 (, B, C) Patient Reason DX O Enter the patient s reason for visit code in field (one to five digits). Do not include decimals. Do not complete fields B & C. 71 PPS Do not complete this. 72 (, B, C) External Cause of Injury For dates of discharge prior to October 1, 2015, enter the ICD-9-C External Cause of Injury in field (one to five digits); OR for dates of discharge on or after October 1, 2015, enter up to seven digits of the ICD-10-C External 18

19 P PROISe 837 Institutional/UB-04 Claim Cause of Injury in field. Do not include decimals. Do not complete fields B & C. 73 Unlabeled Do not complete this. 74 Principal Procedure & Date Do not complete this. 74 ( E) Other Procedure & Date Do not complete this. 75 Unlabeled Do not complete this. The following graphic shows s with sample data and their requirements. Please refer to the detailed notes for each for specific completion instructions. 76 ttending Physician ID NPI Enter the NPI of the attending provider, the provider that ordered the admission or the provider who is responsible for determining the diagnosis or treatment of the patient. 19

20 P PROISe 837 Institutional/UB-04 Claim Qualifier Do not enter the Qualifier. ID (Unlabeled) Enter the attending practitioner s license number. The full professional license number contains a prefix consisting of two alphabetic characters, the six-digit certification number, and a one-character alphabetic suffix. Do not enter hyphens or spaces. If the practitioner's license number was issued after June 29, 2001, enter the number in the new format (for example, D123456). Last Enter provider s last name. First Enter provider s first name. 77 Operating Physician ID 78 Other Physician ID 79 Other Physician ID 80 Remarks (a d) Do not complete this. Do not complete this. Do not complete this. Newborn When billing for a newborn under the mother s beneficiary number, enter the mother s name, date of birth, and social security number in this. Qualified Small Businesses Qualified small businesses must always enter the following message in 80 (Remarks a, b, c, d) of the UB-04: ( of Vendor) is a qualified small business concern as defined in 4 Pa Reason For djustment s Enter one or more of the following reason codes to explain your request for an adjustment: 20

21 P PROISe 837 Institutional/UB-04 Claim 81 (a d) 8001 Change the Patient Control 8002 Change the Covered Dates 8003 Change the Covered/Non covered Days 8004 Change the dmission Dates/Time 8005 Change the Discharge Times 8006 Change the Status 8007 Change the edical Record 8008 Change the Condition s (sometimes to make claim an outlier claim) 8009 Change the Occurrence s 8010 Change the Value s 8011 Change the Revenue s 8012 Change the Units Billed 8013 Change the mount Billed 8014 Change the Payer s 8015 Change the Prior Payments 8016 Change the Prior uthorization 8017 Change the Diagnosis s 8018 Change the ICDN s and Dates 8019 Change the Phys. ID s 8020 Change the Billed Date CC Do not complete this. 21